3/2/10. Hospice Scrutiny From A Z. Objectives. Who s Looking At You? Nebraska Hospice and Palliative Care Partnership

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1 3/2/10 Nebraska Hospice and Palliative Care Partnership Hospice Scrutiny From A Z Objectives At the end of this in-service, participant will be able to: Distinguish between scrutiny related to payment and scrutiny related to patient health/safety and quality of care. List four Federal entities and the type of hospicerelated investigation each one conducts. Explain the difference between MAC and RAC scrutiny Cite the five standards that comprise the Condition of participation entitled Interdisciplinary Group, Care Planning, and Coordination of Services (418.56). Who s Looking At You? 1

2 Hospice Scrutiny State surveyors Licensing / Certification / Complaints/ QIO CAHABA RHHIs / MACs RACs ZPICs OIG FBI HEAT MCS The Alphabet Soup Of Hospice Scrutiny CMS RHHIs/MACs RACs OIG ZPICs HEAT MICs MFCU FBI DOJ Remember When? 1994 Audits in Puerto Rico Operation Restore Trust 1999 Office of Inspector General (OIG) Compliance Guidance for Hospices 2

3 Office of the Inspector General The OIG protects the integrity of programs of the department of Health and Human Services and welfare of beneficiaries. Reports to Congress on problems with recommendations to correct them. Conducts nationwide audits and investigations. Offers compliance program guidance to health care providers. OIG s Compliance Guidance for Hospices Published in 1999 Based on Federal Sentencing Guidelines Same as compliance program guidance for other providers except for the identification of 28 hospice risk areas. Hospice Risk Areas Where the OIG thinks hospices might be vulnerable to fraud or abuse. Fraud: Knowingly and willfully executing, or attempting to execute, a scheme or ploy to defraud the Medicare program. 3

4 Fraud Knowingly and willfully executing, or attempting to execute, a scheme or ploy to defraud the Medicare program. Deliberately deceiving Medicare to gain an unauthorized benefit. Abuse Incidents or practices that are inconsistent with accepted sound medical, business, or fiscal practices that result in: Unnecessary or excessive costs; Improper payment; Payment for services that fail to meet professionally recognized standards of care; and/or, Payment for services that are not medically necessary. Hospice Risk Areas Related to: Medicare Hospice Benefit and the Medicare Conditions of Participation (CoPs). Marketing. Care provided in nursing homes. Billing. 4

5 The PRIMARY Hospice Risk Area Admitting patients that the hospice knew, or should have known, did not meet the admission requirement of a six-month prognosis. Recent OIG Reports Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance with Medicare Coverage Requirements (report #OEI ) September 8, Medicare Hospice Care: Services Provided to Beneficiaries Residing in Nursing Facilities (report #OEI ) September 8, Current OIG Activities 2010 Work Plan Physician billing: Frequency of and total expenditures for physician services under Part A and Part B for hospice beneficiaries. Identify whether physicians double billed hospice services to Part A and Part B. 5

6 Current OIG Activities 2010 Work Plan Trends in hospice utilization Examine the characteristics of hospice beneficiaries, geographical variations in utilization, and differences between for profit and not for profit providers. Why Are They Looking? Changing demographics of the hospice industry. National focus on health care reform. Growth in Medicare payments. Suspected fraud and abuse in the hospice industry. What Do These Numbers Say? Citation: NHPCO National Summary of Hospice Care DATA Non-Profit 67.6% 49% 48.6% 49.6% For-Profit 27.2% 46% 47.1% 46.2% Gov-Owned 5.2% 5.1% <5% <5% Total patients 1.2 Million 1.3 Million 1.4 Million 1.45 Million 6

7 NHPCO Facts and Figures Types of Scrutiny Patient health and safety/quality of care: Subparts C, D (CoPs) Payment related: Subparts B, F, G: Patient Health and Safety Regulatory scrutiny for compliance with the Medicare Conditions of Participation (CoPs) Subparts C and D of the hospice regulations. Concerned with quality of care, health and safety of beneficiaries. CMS Regional Office (RO) and State survey agency (SA) follow the State Operations Manual (SOM) to conduct surveys. Survey results in a Statement of Deficiencies (SOD) that requires a Plan of Correction (POC) to address each cited deficiency. 7

8 Current Status Hospice is at Tier 4 - the lowest priority for surveys unless there is an access to care issue and the provider is desperately needed; or There is a complaint. New hospices are not able to get certified unless they request an initial survey under deemed status through the Joint Commission, CHAP or ACHC. Tier 4 Is Good Because Hospices are under so much scrutiny on the payment side it is a relief to not have to worry about random or regular recertification surveys. Tier 4 Is Not Good Because Providers can get lax with compliance with the regulations; and Get off-track. 8

9 Why Does CMS Do Surveys? To protect hospice patients / Medicare beneficiaries. To assure that the Medicare-certified hospice is meeting minimum health and safety requirements. Types Of Surveys Initial Certification. Recertification survey. Complaint survey. Re-Visit survey: Follow-up survey after a re-certification or complaint survey that resulted in one or more condition level deficiencies. Conducted within 90 days of 1 st survey exit. Can result in an additional Statement of Deficiencies. Potential Survey Outcomes No deficiencies found. Condition-level deficiency. Standard-level deficiency. Finding of Immediate Jeopardy. Complaint substantiated. Complaint not substantiated. 9

10 Deficiencies Standard-level deficiency: Hospice submits a plan of correction. Condition-level deficiency: Hospice submits a plan of correction; and/or Hospice on a termination track. Immediate Jeopardy A situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Only one individual needs to be at risk. Quality Improvement Organizations (QIOs) Created by statute in 1982 previously known as Peer Review Organization (PRO). Goal to improve the efficiency, effectiveness, economy and quality of services for Medicare beneficiaries. Reviewed cases and complaints to determine if professional standards were met. Eventually shifted focus to quality measures and renamed QIOs. 10

11 QIOs, cont d. Mission: - Improving quality of care for beneficiaries; - Protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; and other related responsibilities as articulated in QIO-related law. QIOs, cont d. Who are they? - Mostly private, not for profit organizations with physicians and other health care professionals who can review medical care and deal with patient complaints, expedited reviews. QIOs, cont d. Current status: - CMS awarded contracts to 53 QIOs for the 9 th Statement of Work spanning from August 1, 2008 July 31, Examples of activities: - IPRO in NY working with 7 hospices on quality measures - QIOs in a number of states requesting hospice records to review quality of care and/or determine if there are improper payments. 11

12 CIMRO CIMRO of Nebraska is the Medicare Quality Improvement Organization (QIO) for the state of Nebraska. Working within the 9 th Scope of Work. Our mission is to ensure the quality, effectiveness, efficiency and economy of healthcare services provided to Nebraska Medicare beneficiaries. CIMRO, cont d. Our vision is to make healthcare in Nebraska the nation's best. The Centers for Medicare & Medicaid Services (CMS) administers the QIO program across the country. Under contract with CMS, CIMRO of Nebraska works to promote quality healthcare services, determine medical necessity of services rendered and ensure professionally recognized standards of care are met for services rendered. CIMRO, cont d. The Centers for Medicare & Medicaid Services (CMS) administers the QIO program across the country. Under contract with CMS, CIMRO of Nebraska works to promote quality healthcare services, determine medical necessity of services rendered and ensure professionally recognized standards of care are met for services rendered. Annual Medical Services Review Report (August 08- June 09). 12

13 Payment Scrutiny Who Else is Looking? More Soup Please?! 13

14 The Most Prevalent Types Of Payment Scrutiny MACs Medicare Administrator Contractors (Replacing RHHIs) RACs Recovery Audit Contractors ZPICs Zone Program Integrity Contractors (formerly PSC-Program Safeguard Contractor) OIG Office of the Inspector General HEAT Healthcare Fraud Prevention and Enforcement Action Team HIPAA Health Insurance Portability and Accountability Act 1996 The MACs 14

15 MACs, cont d. National Heritage Insurance Corporation (NHIC) (NGS) Highmark Medicare Services Palmetto GBA Noridian Administrative Services MACs (Formerly RHHIs) Regional Home Health and Hospice Intermediaries (RHHIs) are transitioning to Medicare Administrative Contractors (MACs). All existing hospice providers with a Medicare claims history will remain in their current RHHI assignments until their workload is transferred to a MAC. The workload currently being serviced by an RHHI will be absorbed by the MAC within the first 12 months. In some situations the workload transition may be delayed by an award protest*. Role of the MACs Enroll providers in Medicare. Educate providers about billing requirements. Process claims. Conduct pre and post-may medical record reviews to ensure appropriate payments. CMS provides guidance to these contractors regarding medical review probes (probe edits) and progressive corrective action (PCA) activities. Handle claim appeals. 15

16 Additional Development Requests ADRs: Are initiated by the MAC (RHHI). Can be pre-payment or postpayment. Are usually related to a probe edit. Basically involve technical and medical reviews of hospice claims. The RACs Recovery Audit Contractors Evolved from a three year demonstration project that recouped close to one billion dollars. CMS authorized to make the program permanent and nationwide by January 2010 because it was so successful in recouping money. RACs work on a contingency basis the more improper payments they identify, the more money the RAC will make. 16

17 RACs Purpose To reduce Medicare improper payments through the efficient detection and collection of overpayments, the identification of underpayments and the implementation of actions that will prevent future improper payments. Focus limited resources on where there will be the most return. Current RACs REGION A Diversified Collection Services, Inc. CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RI, and VT. REGION B CGI IL, IN, KY, MI, MN, OH, and WI. REGION C Connolly Healthcare AL, AR, CO, FL, LA, MS, NC, NM, OK, SC, TN, TX, VA, WV, Puerto Rico and the US Virgin Islands. REGION D HealthDataInsights, Inc. MT, WY, ND, SD, UT, AZ, AK, CA, HI, ID, IA, KS, MO, NE, NV, OR and WA, and the territories of Guam, American Samoa and Northern Marianas. Current RACs 17

18 History Of RACs RACs received Home Health and Hospice data in April and May Review of Home Health or Hospice claims began January RACs - Process RACs must seek approval from CMS for any audit areas they wish to review. The approved areas are posted on the RAC website. Provider outreach must be offered prior to beginning audit. The RACs will use the same Medicare policies for review as the MACs LCDs, CMS Manual etc. The RAC Process, cont d. RACs can only review 10% of average monthly Medicare claims (maximum 200) per 45 days, per hospice. 18

19 The RAC Process, cont d. Two types of review: Automated reviews utilize the RAC s propriety software to review claims and kick out obvious errors/overpayments. No review of clinical records. Complex reviews are initiated with a request for records and a determination is made regarding whether an overpayment has been made. The RACs Process, cont d. If an overpayment is identified, a demand letter will be sent. Hospice can pay the demand by check or by offset. Hospice can appeal - same appeal process as currently used with MACs. Challenge If the RAC loses at any level of the appeal, it must return its contingency fee. Clearly the incentive for the RACs will be to not lose any appeals. 19

20 What Is Particularly Scary About RACs? They work on a contingency fee basis RAC contingency fees: Region A % Region B % Region C - 9% Region D 9.49% Current RAC status Some hospices have had RAC contact due to hospital/inpatient related issues. Issues have been approved by CMS for hospitals and DME suppliers and have begun audits in those areas. These can be viewed as indirect probes into hospice services. MACs vs. RACs How do they compare? MACs Paid a set contract price May request unlimited records Can review whatever they choose Provide education to providers MACs can conduct both pre-payment and postpayment reviews RACs Paid on a contingency basis 10% of average monthly claims q 45 days Must have issues approved by CMS prior to review RACs can only conduct post-payment reviews retro to Oct. 1, 2007 but never more than three years 20

21 Similarities Both want to do a good job for CMS. Both can wreak havoc with providers cash flow. Both use the Medicare appeals process for disputing denials. Both use LCD guidelines, CMS coverage manuals, etc. to make denial determinations. Most likely they will both look at similar issues. More MACs and RACs They are not allowed to review the same claims for a patient. However, they can review different claim periods for the same patient. 21

22 HIPAA Established HCFAC the Health Care Fraud and Abuse Control Program A comprehensive, national program to combat health care fraud. Coordinates Federal, state and local law enforcement Funds technical assistance. Created rules to allow prosecution of health care fraud. Provides additional funding for investigation and prosecution of health care fraud. Results of HIPAA/HCFAC Program Safeguard Contractors (PSC) Identify cases of suspected fraud through data analysis. Take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out, and that any mistaken payments are recouped. Support of federal law enforcement in the investigation and prosecution of healthcare fraud cases. 10 PSCs are transitioning to 7 ZPIC zones. 22

23 ARRA/HITECH Another offshoot of HIPAA American Recovery and Reinvestment Act of 2009 includes HITECH (Health Information Technology for Economic and Clinical Health Act). Expands HIPAA s applicability and enforcement and increases civil and monetary penalties for privacy/ security violations. Effective date for compliance February 17, ZPICS Zone Integrity Program Contractors GOALS: To investigate Medicare fraud and abuse through sophisticated data analysis and audits that lead to referrals for investigations. To ensure the integrity of all Medicare claims under Parts A and B. 23

24 ZPIC Background Seven zones have been created based on MAC jurisdictions. New entities have been created in each of the seven zones to perform program integrity for Medicare. The Role of ZPICs Look at billing trends and patterns across Medicare and focusing on companies and individuals whose billings are higher than the majority of providers and suppliers in the community. ZPICs are expected to perform program integrity functions for Medicare A-D, DME, home health, hospice and the Medi-Medi program. Additional Roles for ZPICs Conduct prepay and/or post pay medical review. Conduct announced and/or unannounced onsite audits. Determine and refer actual or extrapolated overpayments for recoupment. Suspend provider payments, based on approval from CMS. Refer providers and beneficiaries to law enforcement. Refer providers for exclusion from Medicare program. 24

25 Some Of The Things A ZPIC May Investigate Potential criminal, civil, or administrative law violations. Allegations extending beyond one provider, involving multiple providers, multiple states, or widespread schemes. Allegations involving known patterns of fraud. Pattern of fraud or abuse threatening the life or well being of beneficiaries. Scheme with large financial risk to the Medicare Program or beneficiaries. Medi Medi Program Medicare-Medicaid Data Match Designed to identify fraudulent billing practices that affect both Medicare and Medicaid. Matching data from both can identify atypical billing patterns that may not be evident when looking at both independently. Currently there are Medi-Medi projects in ten states with plans to expand nationwide. Medical Integrity Contractors MICs will review and audit Medicaid claims and provide education. Significantly increased the resources of CMS and HHS-OIG to fight Medicaid fraud. In 2008 Medicaid ranked highest for improper payments at $18.6 billion compared to Medicare at $10.4 billion. 25

26 Types of MICs Review MICs analyze data and identify issues to be audited. Audit MICs. Education MICs provide education to providers regarding Medicaid payment integrity and quality of care. MICs vs. RACs No limit on the number of claims reviewed. Look-back period is based on individual state look-back protocols. Number of days to respond to record requests based on individual state rules. MICs not paid on a contingency basis, but eligible for bonuses. Current Status of MICs As of July 2009 there were 500 Medicaid audits taking place in 17 states: 44% in hospitals; 29% in long term care facilities; 21% in pharmacies; and, 6% other provider types. Nationwide roll-out by 2009 year-end. 26

27 HEAT Healthcare Fraud Prevention and Enforcement Action Team (HEAT). A new effort between DOJ and DHHS with increased tools and resources to combat fraud with emphasis on prevention. Today we are turning up the heat on perpetrators who steal from taxpayers and threaten the future of Medicare and Medicaid. Fraud Enforcement and Recovery Act of 2009 (FERA) Expands the False Claims Act (FCA) liability and the investigative tools available for FCA prosecution. Amended the FCA in order to increase government s ability to pursue a person or entity suspected of submitting bogus claims. What s next??? Patient Protection and Affordable Care Act - Health care reform bill under consideration in the senate Expands RAC program to Medicare Part C and D Establishes a RAC program for Medicaid 27

28 Hospice Provisions Hospices must submit quality data by 2014 Hospice Compare on the way. After January 1, 2011 a hospice physician or NP must have face-to-face visit with a patient to determine continued eligibility prior to 180 day recertification. All patients over 180 days will be medically reviewed based on a to-be-determined percentage of patients on service over 180 days. Executive Order Signed 11/23/09 When the Federal government makes payments on behalf of program beneficiaries, it must make every effort to confirm that the right recipient is receiving the right payment for the right reason at the right time. Questions 28